General Question for the Week of February 10, 2025

Question:

When coding for intravenous infusions that begin outside the observation unit and continue upon the patient’s arrival, what specific documentation elements must be present to ensure compliance and avoid audit risks?

Answer:

First understand that a common weakness in documentation frequently found during audits is the lack of complete and cohesive recording of start and stop times for intravenous infusions that are initiated outside the observation unit and are infusing when the patient arrives for placement in a bed. When documentation in nursing notes does not reference the receipt of a patient with IV administration actively infusing and/or the continued management of the infusion, as well as the stop time, charges are at risk because the documented information is insufficient for CPT® code assignment.

This question was answered in our Coding Essentials for Infusion & Injection Therapy Services. For more hot topics relating to infusion services, please visit our store or call us at 1.800.252.1578, ext. 2.